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General NPI Number Information
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NPI Number | 1487104667
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Entity Type | Organization
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Legal Business Name | RYAN T PORTER
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Dates
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Enumeration Date | 10/11/2016
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Last Update Date | 10/11/2016
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Provider Practice Location Address
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Address Line | 150 E COOK AVE SUITE 105
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-2060
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Country | US
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Telephone | 847-971-3579
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Fax |
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Provider Business Mailing Address
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Address Line | 513 DEER CROSSING CT
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City | HAINESVILLE
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State | IL
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Zip | 60030-3855
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Country | US
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Telephone | 847-971-3579
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Fax |
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Authorized Official
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Title or Position | OWNERE
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Name | RYAN T PORTER
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Credential | LCPC
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Telephone | 847-971-3579
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180005697
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License Number State | IL
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